Physical

examination

Dr. Laszlo Jakab

Approach to evalution of the

patient

History taking

Physical examination

Laboratory studies

Medical/dental consultation/referral

Dental office

Identification of undetected systemic disease

To identify patients who are taking drugs or medication

To protect any malpractice

Medical consultant

Establish a good patient/doctor relationship

Abbreviated outpatient evaluation

Relatively safe treatment

History taking

Personal dialogue, interview

Display a professional attitude

Evaluate the patient’s mental status

History taking

Patient identification: full name, age, date

of birth, sex, race, marital status,

occupation

Source of information: patient, relative,

previous medical charts, referral letter

Chief complaint 1. Abdominal pain for 1

month 2. Vomiting blood for 1 day

History taking

Present illness: complaints, chronological

order, precise description of all the

symptoms, presence or absence of

symptoms

Past history

Previous illnesses, response to therapy,

previous hospitalization and surgery

Medication allergies: drugs, contrast

media

Immunization: tetanus, pneumonia,

flu,hepatitis, mumps

Trauma: significant injuries, blood

transfusions

Previous diseases,

present complaints

Describe them in chronological order

Ask a special group of questions

When did the complaint start?

Cardiology question group

Respiratory question group

Gastroenterology question group

Urinary tract

Cerebral function

Previous medication and drug allergy

General inspection 1.

1. Nourishment: well nourished, well developed

2. Skin (body hair): moderetly pigmented, no abnormalities, body hair normal

3. Subcutaneous tissue: no edema, the turgor of the skin normal

4. Mucus membranes: moderately blood filled and intact

5. Conjunctiva: moderately blood filled

Sclera: bluish and white

General inspection 2.

6. Throat: moderately blood filled, intact

7. Teeth: replaced, well aligned

8. Lymphoid nodules: no enlarged palpable

lymph nodes

9. Genitals: morphologically intact

10. Breast: no palpable nodules

11. Thyroid gland: not enlarged, no

palpable nodules

Chest organs, blood

circulation 1.

1. Shape of the chest: symmetric

2. The movement of the chest during the respiration: both sides are equal

3. Borders of the lung, lung percussion according to figure

4. The diaphragm movement during the respiration: both sides are equal 2-3 cm

5. The results of lung auscultation: vesicular sounds

6. Pectoral fremitus: both sides are equal

Chest organs, blood

circulation 2.

7. Apex beat: palpable

Location:5th intercostal space in the midclavicular line

8. The relative upper border of the heart is in the: 3rd intercostal space

on the right: does not exceed the right border of the sternum

on the left: in the 5th intercostal space 1 finger with medial from the midclavicular line

Chest organs, blood

circulation 3.

9. Heart sounds:rhythmic, tone is normal, clear, RRR (regular, rate and rhythm)

10. Heart murmurs: no murmurs heard over the heart

11. Radial pulse: regular, rhythmic, equal, frequency=70/min

12. Blood pressure: 120/80 mmHg

13. Arteries: femoral arteries, popliteal arteries, dorsalis pedis arteries, posterior tibial arteries are palpable

Abdomen 1.

Abdomen is at the level of thorax, symmetric, respiratory movement on both sides are equal.

Umbilicus is inverted. Scars are not present.

No pain, defense musculaire (guarding), or any pathologic resistance during superficial and deep palpation.

Bowel sounds +

Abdomen 2.

Liver, dullness, palpation: not enlarged, normal dullness, normal consistency, not sensitive upon touching, no nodes are palpable

Spleen, dullness, palpation: The spleen is not palpable, normal size, percussed between 9th-11th intercostal space and between anterior and midaxillary line.

Kidney: not sensitive, no enlargement during balloting palpation. No costovertebral angle tenderness.

Muscolosceletal system

Joints, bones, muscles: morphologycally

and functionally normal.

Nervous system

1. Pupils: are equal, round, centrally located, and diameter is normal. Response to direct and indirest light reaction, convergence and accomodation are normal. PERLA=pupils are equally reactive to light and accomododation.

2. Muscle stretch reflexes (tendom reflexes): no pathologic reflexes, no pyramidal signs.

Palpation 1

The Posterior Chest

Undress, sitting position

Inspect, palpate, percuss, auscultate

Compare sides: apex and base

Identification of tender areas

Assessment of the shape of the chest

Assesment of the respiratory expansion: unilateral diminution: pleural effusion, lobar pneumonia

Palpation 2

The Posterior Chest

Tactile fremitus: 99, 1-1-1, palpable

vibrations from the lung to the chest wall

Compare symmetrical areas

Increased: lobar pneumonia, the alveoli

filled with fluid, WBC, RBC

Decreased: fluid in the pleural cavity=

pleural effusion or air = pneumothorax

Palpation 3

The Anterior Chest

Supine position

Assesment of respiratory expansion

Assessment of tactile fremitus both sides

of the chest

Identification of a fractured rib: local pain,

tenderness. Compression of the sternum

increase in local pain

Palpation 4

The Arterial Pulse

Radial pulse: heart rate

Rhythm: regular, irregular: premature

contraction, atrial fibrillation

Amplitude:small-weak or large-bounding,

carotid artery, bigeminal pulse

Thrills on carotid artery: vibrations,

stenosis

Palpation 5

The Heart

Supine position, stop breathing

Use the fingerpads

Apical impulse: cardiac apex. Location 5th interspace, medial to the midclav. line, diameter ˃ 2 cm in adults, amplitude: small, gentle, duration ˂ 2/3 of systole

Apical impulse: undetectable in obesity, muscular chest wall

Palpatin 6

The Heart

Apical impulse: displaced in left

ventricular enlargement, mediastinal shift

Apical impulse increased in amplitude:

aortic stenosis, young persons,

hyperthyroidism, severe anaemia

Apical impulse prolonged duration:

hypertrophy of the left ventricle

Thrills = loud heart murmurs:AS, MS,

VSD

Palpation 7

The Abdomen

Quadrants: RUQ, LUQ, RLQ, LLQ

Sections

Relaxed patient, legs flexed at knees, supine

position

Stand/sit on the patient’s right side

Examine painful areas last with warm hands

and short fingernails

Watch patient’s face for signs of discomfort

Palpation 8

The abdomen

Normal structures palpable: normal liver, tip of the normal spleen, lower pole of the right kidney, distended bladder, sigmoid colon, pulsation of the abdominal aorta

Light palpation: abdominal tenderness, muscular resistance (voluntary or involuntary), superficial organs

Deep palpation - masses = malignancy: location, size, shape, consistency, tenderness, pulsations, mobility

Palpation 9

The Abdomen

Assesment of peritoneal irritation:

musculas spasm, abdominal pain on

coughing, on light percussion,

tenderness

Peritonitis = inflammation of the parietal

peritoneum

Palpation 10

The Liver

Below the right costal margin

Use the fingertips of the right hand

Patient takes a deep breath

Edge of the liver palpable: normally soft, sharp, regular

Surface of the liver: normally smooth

Abnormalities: enlargement, hardness, rounded liver edge, irregularity of its surface, tenderness (hepatitis)

Palpation 11

The Spleen

Below the left costal margin

Tip of the spleen

Tenderness

Enlargement = splenomegaly

Palpation 12

The Kidneys

Right kidney

Left hand on contovertebral angle + right

hand on RUQ

Patient takes a deep breath

The lower pole may be palpable

Enlargement: hydronephrosis, tumor

Tenderness et costovertebral angle:

pyelonephritis

Palpation 13

The Aorta

Deep palpation, pulsation

Abdominal mass with pulsation: aortic

aneurysm

Palpation 14

The Neck

Lymph nodes: occipital, cervical, submandibular, supraclavicular, preauricular

Assesment of size, shape, discrete, grouped together, mobility, consistency, tenderness

Normal person: lymph nodes present (small, mobile, discrete, nontender)

Enlargement: regional, generalized

Palpation 15

The Thyroid gland

Palpate behind the patient

Patient swallows

Feel both lobes and the isthmus

Goiter = diffusely enlarged thyroid

Assess: size, shape, consistency,

nodules, tenderness

Palpation 16

The Breasts

Quadrants: upper inner, lower inner, upper outer, lower outer

Tenderness

Nodules = lumps = masses: location, size in cm, shape, consistency (hard,soft), mobility to the skin/underlying chest wall

Cancer: hard, irregular, fixed

Discharge of the nipple: milk, blood, quantity

Palpation 17

The Axillae

Sitting position

Normal person: small, nontender nodes

Enlarged lymph nodes: hard, tender,

intection, breast cancer

Palpation 18

The Anus, Rectum, and

Prostate

Rectal examination

Side-lying position, glove, lubricant

Perianal area: hemorrhoids, perianal abscess

Anus and rectum: carcinoma

Prostate gland: both lobes normally rubbery, nontender, rounded, 2.5 cm in length, no nodules

BPH:5th decade, symmetric enlargement, smooth, obstraction of urinary flow

Cancer: hard

Palpation 19

The Peripheral Vascular

System

Both legs: swelling, symmetry, venous enlargement, ulcers

Inguinal lymph nodes:normal patient nontender, discrete, 1-2 cm in diameter

Femoral pulse: decrease/absence - occlusion

Popliteal pulse: absent . occlusion in the thigh

Dorsal pedis pulse: dorsum of the foot

Posterior tibial pulse: ankle (below the medial malleolus)

Ankle edema: bilateral, unilateral, pitting = depression by pressure

Percussion 1

The Posterior Chest

Percussion: audible sounds, motion of the chest wall and underlying tissues

Technique: the pleximeter finger: hyperextension of the middle finger of left hand, its DIP joints press firmly, avoid contact by other part of the hand (decrease of vibrations)

The plexor: right middle finger partially flexed

Tip of the plexor strike the pleximeter finger

Transmission of vibrations: through the bones of DIP joint, through the underlying chest wall

Strike 2x in 1 location

Percussion 2

The Posterior Chest

Penetration: 5-7 cm into the chest, deep-seated lesions undetected

Thick chest wall: heavier strike required

Appropriate wrist movement

Compare one side with the other, apex to base, sitting position

Percussion notes: intensity, pitch, duration, tympany

Normal case: percussion note resonant

Percussion 3

The Posterior Chest

Abnormal dullness: fluid in the pleural space = pleural effusion (hemothorax: blood, empyema:pus)

Abnormal dullness: solid infection and iflammation in the lung = lobar pneumonia (alveoli filled with fluid, RBC, WBC)

Unilateral hyperresonance: large ptx

Identification of the level of diaphragmatic excursion: dullnes – diaphragm, 5-6 cm distance between levels of dullness on full exspiration and full inspiration

Omit the scapular areas: thick musculosceletal structures

Percussion 3

Summary

Normal case: percussion note resonant, tactile fremitus normal

Lobar pneumonia: bacterial pneumonia, alveoli filled, percussion note dull over the airless area, tactile fremitus increased

Pleural effusion: fluid accumulates and separates the air-filled lung from the chest wall, blocks the trransmission of sounds, percussion note dull over the fluid, tactile fremitus decreased

Percussion 4

Ptx: air in the pleural space, blocks the

transmission of sounds, percussion note

hyperresonant or tympanic over the

pleural air, tactile fremitus decreased or

absent over the pleural air

Emphysema: lungs hyperinflated,

percussion note diffusely

hyperresonant

Percussion 5.

The Anterior Chest

Supine position, compare both sides

Identification of the upper border of liver

dullness

Percussion 6.

The Heart

Supine position

Estimation of cardiac size

Percuss from lung resonance to cardiac

dullnes

Relative heart borders: left, right and

upper border

Percussion 7.

The Abdomen

Relaxed patient, supine position

Patient’s right side

Orientation: tympany predominate –

gastric air bubble

Dullness: liver, spleen, suprapubic area –

distended bladder, enlarged uterus

Percussion 8.

The Liver

Liver dullness

Vertical span in cm, in the right midclav. Line

Increased span: enlarged liver

Decreased span: small liver

Liver dullness disappear: free air present below the diaphragm, sign of perforation

Percussion 9.

The Spleen

Left midaxillary line

Oval area of splenic dullness

Surrounding: lunf resonance, abdominal

tympany

Splenomegaly = enlarged spleen (large

dull area)

Percussion 10.

Ascites

Protuberant abdomen

Ascites fluid sinks with gravity

Dullness outward to central area tympany

Shifting dullness: pazient turns to one

side – dullness shifts

Fluid wawe: impulse transmitted through

the fluid